Practices and experiences of European frontline nurses under the shadow of COVID-19.

The COVID-19 pandemic has caused health professionals to deal with new situations they have not encountered before. Nurses were forced to cope with increased workloads, seriously ill patients, numerous patient deaths, and unresolved ethical dilemmas. This study aimed to examine the lived experiences of nurses across Europe during the first wave of the COVID-19 pandemic. This was a qualitative narrative research study. Eighteen nurses from eight European countries (four each from the UK and Israel, three from Portugal, two each from the Netherlands and Ireland, and one each from Belgium, Italy, and Sweden) submitted narratives about their professional experiences during May-June 2020. The narratives were analyzed using thematic analysis. Seven categories across the narratives were condensed and interpreted into three themes: opportunities and growth, care management, and emotional and ethical challenges. The COVID-19 pandemic has affected nurses emotionally and provided an opportunity to actively develop systems and skills needed to minimize harm and maximize benefits to patients and nurses.

The COVID‐19 pandemic offered European nurses the opportunity to demonstrate leadership, as well as raise their visibility and professional pride.

Nurses described providing effective patient care in partnership with other healthcare professionals while demonstrating creativity, resilience, and flexibility.

During the COVID‐19 pandemic nurses faced emotional burdens and challenges associated with ethical dilemmas.

INTRODUCTION

On March 11, 2020, the World Health Organization declared COVID‐19 a pandemic (World Health Organization, 2020). By the end of January 2022, the Johns Hopkins Coronavirus Resource Center reported more than 401 million cases and more than 5.76 million deaths worldwide due to COVID‐19 (Johns Hopkins University & Medicine, n.d.). Like the rest of the world, European countries were seriously affected with thousands dying (Johns Hopkins University & Medicine, n.d.). COVID‐19 led to an increase in the demand for nurses, with many countries expanding their nursing workforce (Jiang et al., 2020). Consequently, nurses were forced to cope with increased workloads, seriously ill patients, numerous patient deaths, and unresolved ethical dilemmas.

Background

The COVID‐19 pandemic provided challenges to nurses but also gave them the opportunity for greater visibility to present their knowledge, practice, research, and creativity (DeWees & Miller, 2020; Torres Contreras, 2020). The pandemic has also brought greater visibility to community‐based nurses (Bowers et al., 2021). During the global pandemic, leadership in nursing has become increasingly recognized, particularly for its role in decision‐making, solving novel challenges, and providing high‐quality and safe care to patients and families, as well as to their own workforces (Aquilia et al., 2020).

The role of nurses during the COVID‐19 pandemic expands beyond providing the care for patients; nurses serve as a secure anchor allowing integration of all interprofessional teams (Buheji & Buhaid, 2020). The pandemic forced all healthcare professionals, including nurses, to refine the focus of their care. Critical nurses increased their engagement in palliative care of COVID‐19 patients (Rosa et al., 2020). Due to the imposed isolation measures and restricted physical contact in Dutch nursing home, nurses focused on relationship‐centered care both for the residents and their families (Rutten et al., 2021).

During the COVID‐19 pandemic nurses faced various ethical challenges. The ethical challenges cover three main areas: nurses' safety, professional role, and moral distress (Firouzkouhi et al., 2021). In terms of safety, there was the ethical dilemma as to what was the extent of their duty given the scarce resources and lack of personal protective equipment. In their professional role, nurses were ethically challenged when preventing many end‐of‐life patients with COVID‐19 communicating face‐to‐face with their families. Lastly, a significant number of nurses faced moral distress due to the continuous pressure on them to maintain a sufficient allocation of resources to provide safe, high‐quality nursing care, despite the chronic shortage of staff and equipment (Firouzkouhi et al., 2021).

The aim of the study

While there is a fast‐growing body of knowledge on COVID‐19, there is currently no comprehensive collection of nurses' experiences from across Europe or an analysis of how such experiences could influence nurses and nursing practice. Therefore, this study aimed to examine the practices and experiences of nurses across Europe during the first wave of the COVID‐19 pandemic.

METHODS

Design

A narrative approach was used to analyze descriptions written by frontline nurses treating COVID‐19 patients in the healthcare services across Europe.

Recruitment and data collection

A written invitation was sent by one of the authors, the European Regional Coordinator in Sigma Theta Tau International (STTI), to 11 European chapters. The invitation contained an explanation of the study purpose and contact details. The chapters' nurse members were asked to participate by sharing a 250‐word description highlighting the impact on nursing during the COVID‐19 pandemic. Guidelines on topics to include in these descriptions or narratives were provided, namely: (i) quality and compassionate nursing care; (ii) nursing staffing and workforce issues; (iii) new roles, training, and preparation of nurses treating COVID‐19 patients; (iv) the professional image and visibility of nurses; (v) nurses' impact on patient care and advocacy; (vi) the impact of the COVID‐19 pandemic on the future of nursing; and (vii) nurses' contributions to policy and political decision‐making. The study participants did not have any relationship with the authors of the manuscript.

The inclusion criteria comprised registered nurses who were taking care of patients with COVID‐19, regardless of their clinical area, education, or work experience. The data were collected between May and June, 2020.

Data analysis

An inductive thematic analysis was followed (Braun & Clarke, 2006), which encourages researchers to use their knowledge to inductively analyze data, maintaining a deliberate stance of curiosity that allows for reflexivity and awareness of their preconceptions of the data. The data consisted of the nurses' individual experiences and the meanings they attached to them. The data were coded and categorized. Following the decontextualization phase, where the text was considered in isolation from its usual context, the narrative text was coded separately to create categories and generate themes. In the recontextualization phase, the texts were reexamined according to the code units that had been identified. Mind maps and highlighting of texts allowed for the comparison and collation of themes as well as for the presentation of the findings. Each of the themes was explored drawing on specific quotes that highlighted the aspects to be noted. In the first stage, two researchers independently used inductive coding of the themes with each participant's narrative to finally gather and cluster the codes into major categories. In the second stage, two other researchers reanalyzed the collected data and revised the themes. The revised version was discussed, and the final version approved, by all of the authors.

Ethical considerations

Ethical permission was obtained from the Ethical Board of the Nursing School of Coimbra, Portugal (approval #706/09–2020). Study participation was voluntary and no financial incentives were given. Written informed consent was obtained from all participants.

RESULTS

Participants' characteristics

Eighteen nurses (16 female) from eight STTI European Chapters, including from the UK (4), Israel (4), Portugal (3), the Netherlands (2), Ireland (2), Belgium (1), Italy (1), and Sweden (1), submitted their narratives about their experiences during the first wave of the Covid 19 pandemic. The nurses worked predominantly in hospital settings (15), which comprised critical care units (4), adult wards (4), emergency departments (3), and other hospital departments (4).

Themes

The thematic analysis revealed seven categories, which were condensed and interpreted into three themes: (i) opportunities and growth; (ii) care management; and (iii) emotional and ethical challenges (See Table 1).

TABLE 1

Themes and categories

Themes	Categories
Opportunities and growth	Leadership and mentoring
	Visibility and recognition of nurses' value
	Professional pride and self‐esteem
Care management	Team working and the effective management of nursing practice
	The refinement in the focus of nursing care
	Creativity, resilience and flexibility
Emotional and ethical challenges

Theme – opportunities and growth

The theme identified as “opportunities and growth” consists of the three categories discussed below: (i) leadership and mentoring; (ii) visibility and recognition of nurses’ value; and (iii) professional pride and self‐esteem.

Leadership and mentoring

When describing their work, the nurses' most important professional competencies encompassed leadership, role modeling, and mentoring. Leadership skills were about being able to handle unforeseen situations, to design and implement policies, and to work with advocacy: “Significantly, nurses can be the calming voice within the storm and demonstrate their leadership potential. …We are in a position to expand our role as healthcare leaders and ensure that the people we look after feel safe” (I15, UK).

Nurses also said that they are using their experiences of dealing with the COVID‐19 pandemic to teach students and new nurses: “My clinical experiences are very valuable for me as a university lecturer in preparing nurses for the work in current and future disasters” (I11, Sweden). New nurses were also said to have effectively worked as a team: “Thanks to all recent graduates who have ventured to start their first days of work in these conditions” (I10, Portugal). Novice nurses reported on the positive impact of being guided and supported by experienced nurses: “I was supported by senior nurses to step into uncharted territories. These situations made me both uncomfortable and proud of myself, and have shaped me” (I12, UK).

Visibility and recognition of nurses' value

The COVID‐19 pandemic brought not only challenges for nurses but also opportunities. The nurses in this study described an increased visibility of the nursing profession, a raised awareness of nurses' unique contribution: “UK Nurses are proud to have our National Chief Nurse stand with politicians and state the actions we need to take, but some people need help to do this” (I13, UK). The pandemic also brought visibility in other nursing care contexts: “In the year of the nurse, the coronavirus promoted the visibility of nurses' work higher than expected” (I1, Belgium).

The positive reactions from the public emphasized the recognition of the value of nursing in the community. During the pandemic, people termed professional healthcare providers “super‐heroes.” The nurses' descriptions even provided quotes from members of the public: “Wow, a real hero, you are working in the hospital,” and “you're doing a great job” (I4, Israel). The same voices were echoed by nurses in Portugal, “People made us feel like we were superheroes” (I10), and in the UK and Belgium: “We have seen extreme kindness and support from the public who came out in their thousands once a week to applaud the hard work of nurses/carers and the National Health Service” (I12, UK), and “Society fully supported the challenge healthcare providers faced in and out every day” and “The biggest opportunity for the following months and years is to keep this appreciation and recognition” (I1, Belgium). Thanks were expressed in different ways, from patients who recovered – “You saved my life. I thank you so much” (I6, Israel) – as well as from public outstanding initiatives: “In Portugal people with empty houses made them available to health professionals working at the frontline” (I9, Portugal). Public recognition encouraged and strengthened nurses' motivation: “The challenges faced felt more bearable knowing we were appreciated!” (I12, UK), and “COVID‐19 gave ‘caring for’ a new unseen dimension. No greater solidarity was seen before, not only within the nurses' teams, but also by the fact that society fully supported the challenges healthcare providers faced day in and day out” (I1, Belgium).

Professional pride and self‐esteem

Throughout the narratives the message of pride in the nursing profession was evident, as seen in the following comments from across Europe: “Giving my contribution to the COVID‐19 pandemic I think was a way to honour my chosen profession as an ethical and moral duty” (I17, Italy); “During this time, I have never been prouder to both be a nurse and to work with such fantastic colleagues” (I2, Ireland); “Cooperation, trust and a true team spirit. I was a competent nursing leader and the only one able to respond to daily challenges and unpredictability. I've never been as proud as I've felt on this journey” (I14, Portugal); and “Words are hard to find to describe the level of pride I have in the global nursing profession.… The silver‐lining of this global crisis is that nurses have been brought to the forefront and have continued to demonstrate that they have more to offer beyond the core principles of care” (I18, UK).

Nurses described their personal development and professional advancement while working in the pandemic's challenging environment. They reflected on their different outlook on life in general, and on their personal decision‐making and prioritizing, with comments like “This has turned me into a better person. An experience that could make me appreciate life, so I choose to live every moment by tuning in on emotions” (I17, Italy), or “These have shaped me” (I12, UK). Nurses recognized their own value and contribution which in turn promoted their professional self‐esteem.

Theme – care management

The theme identified as “care management” consists of the following three categories: (i) team working and the effective management of nursing practice; (ii) the refinement in the focus of nursing care; and (iii) creativity, resilience and flexibility.

Team working and the effective management of nursing practice

Nurses reported that as members of multi‐professional teams, they incorporated ways of managing care, ensured effective relations and interactions between different parts of the medical care system, and promoted team working:

We worked closely with the infectious disease, occupational health and microbiology teams. Management pathways were developed for all patient groups including those who were homeless and so couldn't isolate at home, and for those who had deteriorated and needed to return to hospital. (I2, Ireland)

Similarly, a participant from Belgium (I1) wrote: “Doctors supported nurses, nurses supported doctors. It was nice to see the excellent cooperation between healthcare workers.” Improvement of teamwork was also mentioned in the majority of the narratives: “The interdisciplinary team came together very rapidly” (I2, Ireland), and “The team united as never before and I felt nurtured and nurtured others” (I12, UK). Teams working together were said to have made every effort to fight the pandemic: “Thanks… to all the nurses who didn't let anyone in the team give up! We were strong, we were united, and we managed to do our best” (I10, Portugal). Receiving empathy and support from colleagues also gave them the strength and confidence to handle difficult situations.

Once the chaos began to settle, never before had I seen a team of healthcare workers (nurses, carers, GPs) and other homecare staff (activity coordinators, housekeepers, chefs, administrators) rally together to enhance the well‐being of the care home residents during a time when they needed to self‐isolate. (I15, UK)

Nurses described integrative ways and initiatives of providing nursing care to patients:

Locally, my organization developed two significant COVID‐19 roll‐out initiatives. One was a respiratory skills team, who would float to all units of the hospital and give expert support in respiratory management and the second, the “PPE (Personal Protective Equipment) Safety Officer” was launched to help ensure our workforce were supported in donning and doffing PPE correctly and safely, working in‐line with Public Health England recommendations. (I18, UK)

Nurses also described the adaptation of routines and rules, mainly to restrict crowding in clinical institutions. Well‐defined rules were drawn to avoid the crossing and clustering of people: “Our routine of entering and leaving the hospital has a series of rules that we must follow” (I9, Portugal).

The refinement in the focus of nursing care

During the COVID‐19 pandemic, nurses utilized strategies to focus specifically on patients' and their relatives' care and activities aimed at stopping the virus from spreading, instead of other activities previously carried out. The increased clinical focus also pushed aside other programs that are not directly related with the COVID‐19 pandemic, such as team development, quality improvement processes, work environment improvement projects, and more. As one participant from Ireland (I2) noted, “The nursing team members focused predominantly on patient contact and monitoring, offering advice, reassurance and support, and escalating care if required.” This sometimes drew on novel modes of communication out of safety concerns:

A policy was adapted and implemented regarding lactation consultants' activities including individual consultations, while maintaining safety rules and avoiding contact with the mother and baby as much as possible.… online system counseling strategies were developed and embedded (professional forums, phone support). (I3, Israel)

The nurses emphasized the importance of their role as patient advocates in preserving their patients' rights. In parallel with clinical activities, they asserted that it is vital for these rights to be maintained even during disasters such as the current pandemic: “There is no substitute for continuous human contact. In my view, patients' rights, such as dignity and equality in healthcare, must be maintained also during hard times” (I5, Israel).

When providing nursing care at the individual patient level, nurses developed and utilized strategies in order to reach out to the public. In health promotion and disease prevention nurses were active on social media reaching out to many people:

Working as an intensive care nurse, I realized the importance of contributing to the dissemination of information targeted to the general public in order to stop the spread of the coronavirus.… My health message has now reached out to more than one million people. (I11, Sweden)

Creativity, resilience and flexibility

Nurses also described their personal competencies as valuable, especially their ability to be flexible, resilient, and creative. Being flexible in nursing care referred to handling the pandemic as the new normal, accepting different ways of working. Flexibility was also necessary so that they could be empathetic when deviating from their protocols to assist relatives to say good‐bye to their loved ones:

From one day to another I became the head nurse of one of the Covid nursing wards and Covid became the only and most important focus for the weeks that followed. Not only was this flexibility expected from me, but flexibility became the new normal. (I1, Belgium)

Being resilient was described as being able to work a long shift with extra hours in a tough environment while wearing protective gear, and moreover still be ready to take on new work and tasks. The nurses described how such tough situations gave them strength and confidence and made them feel optimistic and able to see opportunities in nursing care. The nurses described the importance of being creative and flexible, especially when developing nursing practice for elderly patients in isolation, with comments such as “Many innovative ideas have initiated practices so we can ensure that older persons living in care homes still engage in social activities, have regular exercise, have access to outdoor gardens, and have their days filled with fun and laughter” (I5, Israel), and “However, as new protocols and procedures were introduced, they have now been accepted as the new norm” (I16, Ireland).

Theme – emotional and ethical challenges

As the theme identified as “emotional and ethical challenges,” the major challenges in nursing care were identified by the participating nurses as an emotional burden, communication difficulties and restrictions, dealing with uncertainty, and working when the medical knowledge is only starting to develop. As one nurse from the UK (I13) commented, “Nurses and carers put on the protective equipment available and soothe scared residents who no longer see familiar faces.”

Nurses felt social isolation from family, neighbors, and those in society who identified them as nurses working on the frontline: “We became social outcasts. …Family members urged us to stay at home” (I4, Israel). Caring during the pandemic triggered uncertainty and stress among nurses: “It isolates you, it scares you, and for some, it kills you” (I13, UK). Living with the inherent professional risk of becoming infected with COVID‐19 challenged their emotional management: “The COVID‐19 pandemic means that this coronavirus can have a severe effect on anyone, not only those belonging to a risk group” (I11, Sweden).

Nurses faced ethical dilemmas related to the end of life of corona virus patients. For example, one of the issues concerned whether family visits could be permitted for a dying COVID‐19 patient: “Now, as nurses, we have a difficult decision to make” (I7, the Netherlands). The high numbers of COVID‐19 patients who died increased the nurses' stress and emotional burden, as shown by comments like “Normally nurses are shocked when more than one patient dies, now this is considered ‘normal’” (I7, the Netherlands), and “I can't deny the toll each death has taken on me, as we fight for every single life” (I12, UK).

DISCUSSION

This study aimed to discover the common experiences of European nurses under the shadow of the COVID‐19 pandemic. A thematic analysis of 18 narratives from frontline nurses working in eight European countries revealed three main themes: opportunities and growth, care management, and emotional and ethical challenges. Nurses described their challenges and reorganizations in various European healthcare systems during the pandemic. Indeed, healthcare systems worldwide have had to face challenges and changes according to this new situation. The discussion will focus on each of these main themes.

Opportunities and growth

The unconventional situation of COVID‐19 highlighted nurses' leadership qualities, mentoring, personal example, mutual support, and teamwork. These have all played an important role in the reorganization of medical and nursing practice and in the collaboration of multidisciplinary teams. The literature contains several reports dealing with nursing leadership during the COVID‐19 pandemic. For example, Italian frontline nurses described changes in nursing leadership roles, such as a single designated nurse becoming the COVID‐19 coordinator through whom all communication is passed (Catania et al., 2021). Leadership moderated the association between fear of COVID‐19 and nurses' secondary trauma, psychological distress, and turnover intention. Namely, when nursing leadership was high, this association decreased (Khattak et al., 2021).

Participants in this study reported on nurses' increased visibility and recognition by society. Indeed, especially in the first wave of the pandemic, nurses and nursing care were positively represented in the media at all levels of the pandemic response (Nayna Schwerdtle et al., 2020). Despite this immediate positive effect, questions have also arisen about the long‐term implications of this “hero” enthusiasm. Caution has been advised against exaggeration and over‐enthusiasm in describing nurses as heroes since this can overshadow acute problems within the profession that are not being adequately addressed. These include inadequate working conditions and a lack of nurses (McAllister et al., 2020).

In this study it was found that nurses' visibility improved. However, the literature shows differing reports. Namely, the findings of a number of studies emphasized the lack of nursing leadership in the context of nursing practice visibility. For example, nurses did not have a sufficiently strong voice to speak about their professional interests and concerns, which were therefore not addressed in the main (Daly et al., 2020). Similarly, Rosser et al. (2020) found not being visible was one of the three key characteristics of nursing leadership during the COVID‐19 pandemic (in addition to not being collaborative and not being advocative of the personhood of citizens). Nevertheless, in this study, it seems that the participants did feel a sense of leadership at the personal level. This difference may be due to the fact that most of the nurses in the study were staff nurses working at the bedside and not nurses holding managerial positions.

In this study the nurses described their personal growth at becoming adaptable to the organizational measures established during the COVID‐19 pandemic. Nurses described their increased feelings of professional pride and self‐esteem. Distributing knowledge in clinical practice was rewarding for the nurses in this study and they felt satisfaction at being able to prepare new nurses based on their own clinical experience. This is supported by similar findings from other studies. Geriatric nurses working in nursing homes in four countries (Spain, Italy, Peru, and Mexico) reported on their professional pride and perceived satisfaction from the happiness and gratitude felt by the nursing home residents and their families (Sarabia‐Cobo et al., 2021). Nurses in China also expressed a sense of professional pride and happiness in being on the front line to fight COVID‐19 by providing patient care and saving patients (Zhang et al., 2021).

Care management

The findings of this study emphasized the importance of multi‐professional team working and mutual support. This is supported by previous studies. For example, a multidisciplinary team that included a diabetic nurse practitioner, a diabetes physician, a dietitian, and a social worker was required to streamline communication and transfer information within the team and to their patients, which contributed to the mental support of team members (Waizinger et al., 2021). Also, frontline nursing home staff described their pride in their teamwork to provide the best quality of care to nursing home residents, citing their teamwork as an important factor affecting their ability to work during the pandemic (White et al., 2021).

The nurses described how they were required to make adaptions or refinements to the foci of their nursing care. Refined professional competencies included being able to disseminate pertinent information about COVID‐19 to their patients, nurses, and the general public, including on social media; to improve their leadership skills; to adapt more to teamwork; and to increase patient safety. Similarly, heads of medical units and nurses in Spain reported that they focused on shared leadership and the sharing of information, and had high levels of trust while overseeing individual leadership and social contacts. These all led to reduced levels of COVID‐19 contagion (Salas‐Vallina et al., 2020). Another study found that refined management strategies in non‐isolated areas of a general hospital led to effective COVID‐19 prevention (Xu et al., 2020). Healthcare workers learned to work in a redesigned format, were exposed to clinical challenges, acquired additional skills, and faced difficulties, all of which were accompanied by uncertainty, risk of infection, threat of morbidity, and unusual workloads (Schwarz & Bouckenooghe, 2021). Indeed, nurse managers in mental health centers reported on the change from a familiar routine to a new reality with family members' and volunteers' visits forbidden, and working in capsules (Kagan et al., 2021).

Nurses in this study reported the need to be resilient, creative, and flexible. Similarly, in order to respond effectively and to strengthen organizational capacity, senior and middle level managers, as well as staff clinicians, were required to be agile and resilient (Zarzaur et al., 2020). Among the personal competencies that helped the study participants to be able to work long shifts in a tough environment was their resilience. Personal resilience has been shown to negatively predict COVID‐19 anxiety among nurses (Labrague & De Los Santos, 2020). Moreover, among healthcare providers, resilience has been observed to be associated with lower stress, anxiety, and fatigue and sleep disturbances (Huffman et al., 2021). Given the contribution of resilience to reducing negative psychological effects during a pandemic, healthcare systems should implement the enhancement of resilience among nurses.

Descriptions of nurses' creativity during the pandemic appear in the literature. Nurses working in the ICU found innovative and creative ways of using technology to allow family members to see patients (Luttik et al., 2020), and communicate with physicians and nurses (Negro et al., 2020). Pain management nurses used creative ways to address pain felt by isolated patients, moving patient‐controlled analgesia pumps outside rooms, and when required, administrating medicine from a distance (Sowicz et al., 2021). In this study, nurses also described being flexible. This is supported by a recent study where the flexibility of nursing home staff has been demonstrated by their ability to fulfill many roles simultaneously, for example, being “caregivers, entertainers, spiritual companions, family members,” according to a nursing home administrator (White et al., 2021).

The nurses emphasized the importance of adopting approaches and practices in this new COVID‐19 world. These findings are similar to other reports on the development of new approaches due to the pandemic in various clinical arenas. Among these are cancer care, where new approaches involved investing in infrastructure to facilitate virtual consultations, prioritizing cancer surgery over elective operations, and implementing widespread testing to ensure relatively COVID‐19‐free hospitals that are safe for oncology patients and staff (Butler et al., 2020). Other new approaches included involving family members in the virtual care of patients with COVID‐19, organizing a daily scheduled progress report via telephone or video with the spokesperson of the family, and making the well‐being of the family part of the communication (Maaskant et al., 2020). Thus, the COVID‐19 pandemic has contributed to finding appropriate solutions aimed to address specific patient needs.

Emotional and ethical challenges

As in many other reports, nurses in this study reported severe emotional strain related to work overload, the suffering and death of patients, and to social stigma stemming from their status as healthcare workers dealing with a feared disease. Historically, epidemics have been accompanied by stigma, discrimination, and xenophobia (Villa et al., 2020). Similar to this study, nurses in China during the COVID‐19 outbreak have faced discrimination, isolation, patients with negative emotions, separation from their families, and burnout (Hong et al., 2021). Fernandez et al. (2020) also reviewed studies on nurses' experiences during pandemics and found a significant emotional impact from providing patient care.

Ethical competencies shown by this study's participants demonstrate their desire to work according to a code of ethics. Indeed, as reported by Robert et al. (2020), the imbalance between utilitarian and individual ethics has led to unsolvable discomfort for caregivers and raised ethical dilemmas. According to Robert et al., the prioritization methods for triage during the COVID‐19 pandemic have violated traditional ethical principles, including doing the greatest good for the greatest number. What was actually done during the pandemic included prioritizing COVID‐19 patients most likely to survive the current illness or younger patients, and prioritizing on the basis of first come, first served (Robert et al., 2020).

Other emotional considerations are related to unique aspects of COVID‐19 patients' care, such as dying alone in isolation, the loneliness of patients who were prevented from meeting with family members, and the demands of strict distancing and separation. As reported by an ICU nurse, among the things that greatly troubled her and the families of patients who died was whether the patient died alone. Nurses assured families that their family members were being cared for and not dying alone (Luttik et al., 2020).

LIMITATIONS

The study has several limitations. First, it is not possible to indicate causality but rather only the associations between the COVID‐19 pandemic and the subjective experiences of nurses on the frontline of patient care. Second, the sample size was limited and all the participants were self‐selected nurses, so further larger studies would be warranted. Third, since we included nurses from different countries, there is a possibility that a social desirability or competitiveness to embellish the reality may have been at play. Finally, the ratio of female to male participants was 8 to 1, therefore the nurses' perceptions were skewed to the female point of view.

CONCLUSIONS

The COVID‐19 pandemic has changed much about nursing and has provided an opportunity to actively develop systems and skills needed to minimize harm and maximize benefits to patients and nurses. The themes identified in this study, including opportunities and growth, care management, and emotional and ethical challenges, present a new opportunity for a significant reorganization of nursing practice.

The study's central findings address the need to adapt clinical practice to the complex reality of isolation and social distance. The issues of emotional burden and ethical dilemmas in decision‐making highlight nurses' main challenges during the pandemic.

Relevance for clinical practice

On an individual level, nurse managers are required to identify nurses at risk for an emotional burnout and offer them support. The consequences of pandemics raise issues that are universally applicable across countries. Policymakers are required to formulate policies to support dealing emotionally with the consequences of the pandemic, provide ethical decision‐making support, and leverage the strengthening of professional pride and nurses' visibility by the public for advancing the status of nursing at the professional and general public levels. The changes in the public image and influence of nurses can shape future discussions on the role and remit of nurses in policy development and practical care.

CONFLICT OF INTERESTS

The authors declare they have no conflict of interest.

AUTHOR CONTRIBUTIONS

Study design: Marion Lynch, Marie‐Louise Luiking, Semyon Melnikov, Ilya Kagan, Charlotte Jakab‐Hall, Helena Felizardo, Peter Vermeir, Lisa Langan. Data collection: Marion Lynch, Marie‐Louise Luiking, Semyon Melnikov, Ilya Kagan, Charlotte Jakab‐Hall, Helena Felizardo, Peter Vermeir, Lisa Langan. Data analysis: Helena Felizardo, Marie‐Louise Luiking, Semyon Melnikov, Ilya Kagan. Manuscript writing: Semyon Melnikov, Ilya Kagan, Marie‐Louise Luiking, Helena Felizardo, Lisa Langan.